An estimated 20 to 22 veterans die of suicide each day, at an average age of 60. While it is unknown how many of those deaths occur at VA facilities, they include a 76-year-old who shot himself in a parking lot of a New York hospital in August 2016, a veteran of Afghanistan who hanged himself at age 32 in a Tennessee hospital in November 2016, a 63-year-old Navy veteran who shot himself in a car at a North Carolina hospital and a 35-year-old Marine who overdosed on fentanyl at a Massachusetts VA psychiatric facility.

Last summer, then-VA Secretary David Shulkin, who is also a doctor, addressed the so-called “parking lot deaths,” saying the veterans may choose to kill themselves at VA facilities in part because they don’t want their families to discover them.

“It’s more than a suicide,” said Dr. Jose Mathews, former chief of psychiatry for the St. Louis VA hospital system. “It’s a veteran making a statement about their frustration with the VA as an organization.”

Mathews filed a federal whistleblower complaint in 2013 that claimed mental health care staff treated patients only a few hours a day and artificially inflated their work hours. He quit the St. Louis system last month, and now works through telemedicine with the VA in Utah.

“I was getting tired of butting my head against a brick wall on the issue of access to care,” Mathews said.

Crews’ suicide launched investigations by the hospital and the VA’s Office of Inspector General, which will produce a public report. Crews’ health care history will also be reviewed by a medical team outside the VA system “to see if anything was missed,” said Keith Repko, medical center director of the St. Louis VA.

Security around the emergency room entrance at the hospital on North Grand Boulevard probably will be tightened, Repko said. There are currently no metal detectors at the entrance, and VA police are not permanently stationed there.

Crews had no medical appointments the day he died, and was not seeking emergency care, hospital officials said.

“It looks like he purposely came here to commit suicide,” Repko said. “It is obviously a very tragic event and our condolences go out to the family.”

Crews, who served in Vietnam with the Marines, was buried at Jefferson Barracks National Cemetery this month.

Repko stressed that there is help available to any veteran with suicidal thoughts. Unlike other medical issues, crisis mental health care is available to any veteran regardless of his or her time served or reason for discharge from the military.

The hospital has three providers on its suicide prevention team and is working to hire a fourth. Same-day appointments are available in urgent mental health situations, officials said.

“Patients that come here get the care they need that day,” said Fred Metzger, associate chief of mental health, pointing out that the majority of veterans who died of suicide had not been under treatment or seeking care at the VA.

There have been no other suicides reported on site at St. Louis VA facilities. In 2013, a veteran in an inpatient unit at Jefferson Barracks medical center removed a ceiling tile in an attempt to hang himself before being stopped by a staff member, officials said.

An Iraq war veteran, Jerrod Kershaw, was shot and killed by police in July 2017 after a standoff on Interstate 55 near Festus. The 30-year-old was being treated for several health issues including diabetes and post-traumatic stress disorder. His mother, Cynthia Kershaw, said she is disappointed in the VA, where she took her son regularly for appointments.

“We were there a lot and we didn’t get anything accomplished,” Cynthia Kershaw said. “They didn’t take him seriously at all. They turned their back on us.”

Mathews, the VA whistleblower, blames Kershaw’s death in part on low staffing at John Cochran. Kershaw attempted to access mental health care in May and June 2017 and was denied because the hospital was not accepting new referrals, according to medical records provided by Mathews.

Three months before Kershaw’s death, Mathews sent an email to Repko, Metzger and other VA officials outlining his concerns about staffing levels.

“The current staffing is grossly inadequate to provide safe and timely mental health care at this busy clinic,” Mathews wrote. “I am hoping that you will follow up on my disclosure to remedy this situation at the earliest before an avoidable tragedy.”

Concerns about mental health care have been raised since 2012, when a federal review of John Cochran and Jefferson Barracks hospitals found that staff did not always follow up as required with mental health patients, including those at high risk of suicide.

At the time of Mathews’ whistleblower complaint in 2013, the wait for mental health treatment in St. Louis was a month or longer. A federal investigation found 12 out of 20 patient records from the St. Louis VA had been altered to shorten the wait times by marking “complete” prior to the patients’ scheduled mental health appointments.

A broader investigation found lengthy wait lists nationwide that caused delays in care and deaths of veterans. Since 2014, wait times for medical appointments have improved, according to federal reports.

Overall, 95 percent of mental health, primary and specialty appointments are made within 30 days, putting the St. Louis system in the top one-fifth of VA facilities, according to a 2016 update.

Now mental health appointments can be made within three to five days for new and established patients, local hospital officials said.

There is a full-time equivalent of 2.6 psychiatrists at the John Cochran facility, officials said. Mathews claims the number of available doctors was often lower.

Hospital officials said psychiatrists fill in via teleconference or are reassigned from other clinics to keep the same level of staffing, and that no veteran has been denied care.

“Any veteran, if they’re in a crisis situation, we will help them,” Repko said.

If you’re thinking about suicide, are worried about a friend or loved one, or would like emotional support, the Lifeline network is available 24/7 across the United States. Call the National Suicide Prevention Lifeline at 800-273-TALK (800-273-8255) to reach a trained counselor. Use that same number and press “1” to reach the Veterans Crisis Line.